7.

Physical and cognitive function

Nicholas Steel Department of Public Health and Primary Care, University
of Cambridge
Felicia A. Huppert Department of Psychiatry, University of Cambridge
Brenda McWilliams Department of Public Health and Primary Care,
University of Cambridge
David Melzer Department of Public Health and Primary Care, University
of Cambridge

The results presented in this chapter show that:

• There is considerable variation in the level of physical impairment
between age groups. The prevalence of reported physical functional
limitation is surprisingly high at the youngest end of the sample, with 43%
of respondents in their 50s reporting difficulty with mobility and 13%
reporting difficulty with a basic activity of daily life (self-care). At the
same time, most (58%) of the respondents in their 80s and older report no
difficulties with basic activities of daily life and 17% report no difficulty
with mobility functions.
• The variation in the level of impairment by occupational class is also
considerable. Respondents with routine and manual occupations report up
to twice as many difficulties with physical function as those with
managerial or professional occupations. This occupational class disability
gap is equivalent to the disability gap between age groups 10–15 years or
more apart.
• Walking speed slows dramatically with age. Only around one in forty
people aged between 60 and 64 walk more slowly than 0.4 metres/second,
compared with one in five at age 80 and over. This deterioration in
walking speed is more marked in women than in men.
• Chronological age is the strongest determinant of scores on the objective
cognitive tests, whereas scores on the subjective measure (self-reported
memory) are more strongly influenced by education and occupational class
than by age.
• There was a very high level of forgetfulness in the sample, particularly in
the older groups. Over two-thirds of the oldest group forgot to carry out
actions that they had earlier been instructed to perform. Assuming that the
measures of forgetfulness used in ELSA are indicative of forgetfulness in
daily life, these findings raise concerns about activities such as
remembering to take medication, pay bills or take safety precautions such
as turning off the cooker.
• Although older respondents in general perform less well than younger
respondents on the cognitive tests, older respondents (aged 75 and over)
who have a degree or higher education often performed as well as, and

© Institute for Fiscal Studies, 2004

Physical and cognitive function

sometimes better than, younger respondents with no educational

qualifications. This trend was particularly strong in the case of numerical
ability, where the youngest group with no qualifications gave fewer correct
responses than older groups with intermediate education or a degree or
higher education.
• There is an interesting pattern of gender differences on the various
cognitive measures. Women performed better than men on most of the
memory tests, while men performed better than women on most of the
executive function tests. The gender difference on memory is in line with
many published studies (Huppert and Whittington, 1993; Portin et al.,
1995; Maitland et al., 2000), but the gender difference on executive
function measures has received relatively little attention to date.

This chapter provides a cross-sectional description of physical and cognitive

function among people aged 50 and over in England. Disability or impairment
of function is a key marker of population health at all ages. In older people,
disability and impairment measures are especially useful, as older people often
have more than one illness, and disability measures are a good way of
quantifying the overall impact of several coexisting conditions on a person’s
ability to function. Physical and cognitive function are covered together in this
chapter, because both profoundly influence independence in older people, and
it is likely that they have many of the same underlying causes. This chapter
complements the detailed information about symptoms, diagnosed illness and
health-related behaviours reported in Chapter 6.
England is experiencing a prolonged period of increasing life expectancy and
population ageing, in common with most countries around the world. There is
considerable uncertainty and debate about the likely effects of this population
ageing, in particular about how many added years of life will be spent with a
disability and about which groups within the population will suffer most from
poor health, disability and impaired function. Disability has powerful effects
on individual well-being, on the need for informal help and health care and on
long-term care needs and costs (Gill et al., 2001). Good information on
disability and all levels of function is vital for understanding and informing
policy responses to population ageing.
This chapter describes the measures of physical and cognitive function used in
ELSA wave 1, and then gives the main findings. The prevalence of physical
and cognitive impairment by age, sex and occupational class, as well as the
prevalence of different types of disability, is shown. For occupational class,
the National Statistics socio-economic classification (NS-SEC) is used. A full
breakdown of the findings is shown in the tables in the Annex to this chapter.
The chapter updates the data for England from previous surveys of disability
(Box 7.1). The results presented here are the first results from a national
survey in England to use such a broad range of measures of both physical and
cognitive function.
The population studied in the first wave of ELSA is limited to people living in
the community and does not cover institutions. The Health Survey for England
2000 found that 4% of the total population aged 65 and over were resident in

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 Physical and cognitive function

care homes, with a progressive increase in the proportion of the total

population resident in care homes, up to those aged 90 and over, where three
in ten people were resident in care homes. The true population burden of
impairment and disability is therefore likely to be greater than that found in
ELSA, especially at the top end of the age distribution. ELSA also has limited
information from proxies.

Box 7.1. Previous British surveys of disability

Previous major national surveys of the disabled population in England include those
undertaken in 1969, 1985 and 1996 (Martin, Meltzer and Elliott, 1988; Grundy et al.,
1999). The 1985 survey of disabled adults in private households was one of four
linked surveys of disabled adults and children living in private households and
communal establishments, conducted by the Office of Population Censuses and
Surveys between 1985 and 1988. Both the 1985 and the 1996 survey screened a
nationally representative sample population to identify those with a disability, but the
screening questions were different.
Several other surveys have included questions on disability. The Health Survey for
England (HSE) included questions on disability in 1995, 2000 and 2001 (Bajekal,
Primatesta and Prior, 2003; Hirani and Malbut, 2002; Prescott-Clarke and Primatesta,
1997). The same questions were asked in HSE 1995 and 2000, and covered
incontinence and limitations in functional activities (seeing, hearing, communication,
walking and using stairs) and in activities of daily living (ADLs) – getting in and out of
bed or a chair, bathing, washing, eating and toileting. The General Household Survey
in 1998 had questions on disability in those aged 65 or over (Office for National
Statistics, 2000). The Medical Research Council Cognitive Function and Ageing
Study estimated the prevalence of limiting disability in people aged over 65 in
England and Wales (Parker, Morgan and Dewey, 1997). The Allied Dunbar National
Fitness Survey asked questions about current and past activity in adults, and
included a physical appraisal (Skelton et al., 1996).

7.1 Defining and measuring physical

function
Physical function is a person’s ability to perform normal physical activities of
daily living. Disability occurs when a person has problems with physical
function, and is commonly defined as a restriction in a person’s ability to
perform normal activities of daily living (Verbrugge and Jette, 1994). The
World Health Organisation (WHO) in 1980 distinguished this concept of
disability from impairment and handicap (World Health Organisation, 1980).
Impairments are concerned with the abnormalities of body structure and
appearance and with organ or system function; disabilities reflect the
consequences of impairment in terms of functional performance or inability to
undertake activities considered normal; and handicap refers to the
disadvantage experienced by an individual as a result of impairments or
disabilities. WHO replaced the 1980 International Classification of
Impairments, Disabilities and Handicaps (ICIDH) classification in 2001 by the
International Classification of Functioning, Disability and Health (ICF)
(World Health Organisation, 2001), and ICF retains the widely accepted
concept of disability as a reduction in a person’s functional performance.

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Physical and cognitive function

Information regarding physical function was collected via self-report in this

wave of ELSA, with the exception of walking speed, which was directly
observed. Additional performance tests will be conducted during the nurse
visit in wave 2 of ELSA in 2004.
The core questions about physical function in ELSA fall into one of three
domains: activities of daily living (ADLs) or self-care activities; instrumental
activities of daily living (IADLs) or activities necessary for independent living
in a community; and mobility (or lower-limb function), here reported jointly
with upper-limb function (Pearson, 2000). In addition, participants were asked
about problems with eyesight, hearing and incontinence. Participants aged 60
years and older were asked about falls, both with and without medical
treatment, and were timed over two 8-foot-long walks. The questions are
designed to be comparable where possible with those asked in the Health and
Retirement Survey (HRS) in the USA, a sister survey to ELSA (Wallace and
Herzog, 1995).

Mobility measures, activities of daily living (ADLs) and

instrumental activities of daily living (IADLs)
These were assessed using show cards. Yes/no response codes were used, in
order to be consistent with recent waves of HRS, where a yes/no response was
used for the telephone interviews (Health and Retirement Survey, 2003).

Mobility (leg) and arm function

To assess mobility and arm function, respondents were shown a card and the
following text was read to them: ‘We need to understand difficulties people
may have with various activities because of a health or physical problem.
Please tell me whether you have any difficulty doing each of the everyday
activities on this card. Exclude any difficulties that you expect to last less than
three months. Because of a health problem, do you have difficulty doing any
of the activities on this card?’ (Box 7.2).

Box 7.2. Show card for mobility, arm function and fine motor function

1 Walking 100 yards

2 Sitting for about two hours
3 Getting up from a chair after sitting for long periods
4 Climbing several flights of stairs without resting
5 Climbing one flight of stairs without resting
6 Stooping, kneeling, or crouching
7 Reaching or extending your arms above shoulder level
8 Pulling or pushing large objects like a living room chair
9 Lifting or carrying weights over 10 pounds, like a heavy bag of groceries
10 Picking up a 5p coin from a table
96 None of these

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 Physical and cognitive function

Respondents were also timed over an 8-foot-long walk (twice) and asked the
following mobility question, drawn from the US Third National Health and
Nutrition Examination Survey (NHANES III): ‘By yourself and without using
any special equipment, how much difficulty do you have walking for a quarter
of a mile?’ (Lan et al., 2002; US Third National Health and Nutrition
Examination Survey, 2003).

Activities of daily living (ADLs) and instrumental activities of daily living

(IADLs)
To assess ADLs and IADLs, respondents were shown a card and the following
text was read to them: ‘Here are a few more everyday activities. Please tell me
if you have any difficulty with these because of a physical, mental, emotional
or memory problem. Again exclude any difficulties you expect to last less than
three months. Because of a health or memory problem, do you have any
difficulty doing any of the activities on this card?’ (Box 7.3).

Box 7.3. Show card for ADLs (items 1–6) and IADLs (items 7–13)

1 Dressing, including putting on shoes and socks

2 Walk across a room
3 Bathing or showering
4 Eating, such as cutting up food
5 Getting in or out of bed
6 Using the toilet, including getting up or down
7 Using a map to figure out how to get around in a strange place
8 Preparing a hot meal
9 Shopping for groceries
10 Making telephone calls
11 Taking medications
12 Doing work around the house or garden
13 Managing money such as paying bills and keeping track of expenses
96 None of these

Further measures for those reporting difficulties with ADLs or IADLs or

mobility
Those reporting difficulty with one or more ADL, IADL or mobility function
were asked further questions. They were asked if anyone ever helped with the
activities they had problems with. If they replied that somebody helped them,
they were shown a card and asked, ‘Who helps you with these activities?’
(Box 7.4).
Those reporting difficulty with one or more ADL, IADL or mobility function
were also asked if they used any of the following items, from a list read aloud:
1. a cane or walking stick?
2. a Zimmer frame or walker?

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Physical and cognitive function

3. a manual wheelchair?
4. an electric wheelchair?
5. a buggy or scooter?
6. special eating utensils?
7. a personal alarm?
8. none of these [exclusive code]?
The interviewer was instructed to code all items that applied.

Box 7.4. Show card for who helps with activities

1 Husband or wife or partner

2 Mother or father
3 Son
4 Son-in-law
5 Daughter
6 Daughter-in-law
7 Sister
8 Brother
9 Grandson
10 Granddaughter
11 Other relative
12 Unpaid volunteer
13 Privately paid employee
14 Social or health service worker
15 Friend or neighbour
95 Other person

Other physical function measures

Respondents were asked whether they had fallen down in the last two years
(for any reason) and, if so, how many times they had fallen down in the past
two years and whether in any of the falls they had injured themselves seriously
enough to need medical treatment.
Respondents were asked to rate their eyesight (using glasses or corrective
lenses as usual) and hearing (using a hearing aid as usual) respectively using
the following five response categories: excellent, very good, good, fair or
poor.
Respondents were asked about incontinence as follows: ‘During the last 12
months, have you lost any amount of urine beyond your control?’.
Again, all these questions were designed to be comparable with HRS.

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7.2 Defining and measuring cognitive

function
There is known to be a broad spectrum of cognitive capability among middle-
aged and, especially, older people, with dementia at one extreme and
maintained function at the other. If we consider the full spectrum, the overall
human and economic costs associated with cognitive impairment and
cognitive decline are very high. While the prevalence of dementia is low
before the age of 70 (around 1.4% for ages 65–69, rising to 4.1% for ages 70–
74 (Hofman et al., 1991)), the presence of mild cognitive impairment may
nevertheless interfere with work performance, the management of finances
and social activities. Indeed, independence in later life is as much determined
by mental ability as by physical ability.
Progressive age-associated decline in memory, name-finding, complex
decision-making and speed of information-processing is common throughout
late middle age and later life, and may lead to social withdrawal and
depression. Many of the decisions that individuals make about retirement,
health and housing in later life are complex and may be compromised by
impairments in decision-making ability or other aspects of memory and
executive function, including planning, organisation and mental flexibility.
Numerical skills, such as quantitative reasoning, appear to decline markedly as
individuals age. A classical longitudinal study showed that older individuals
declined more on number skills than on any other primary mental ability over
a seven-year period (Schaie and Strother, 1968). In addition to marked
longitudinal decline within an age cohort, this study and others also found
substantial cohort differences, and these will be addressed in future waves of
ELSA.
Surprisingly little is yet known about the biological, social and environmental
factors that determine cognitive impairment or the rate of cognitive decline in
individuals. There is some evidence that cardiovascular disease is moderately
associated with cognitive impairment in the general population (Breteler et al.,
1994), but less is known about the association of cognitive performance and
risk factors such as hypertension, where results have been inconsistent (e.g.
Posner et al., 2002). Some studies have shown a relationship between
cognitive performance and self-reported health and level of physical activity
(Christensen et al., 1996; Hultsch, Hammer and Small, 1993), but the size of
these associations is very modest.
Environmental or contextual factors appear to play a role in self-reported
cognitive capability in that the functional consequences of cognitive
impairment, like physical impairment, depend on environmental demands. For
example, it has been reported that memory complaints are more common
among individuals in demanding occupations than among those in clerical and
manual occupations, even though memory test performance is better in the
former group (Rabbitt and Abson, 1990). A full understanding of how
individuals make the economic, social and lifestyle decisions associated with
retirement requires an assessment of key aspects of cognitive function, along
with information about their health and social environment.

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The cognitive measures selected for ELSA cover a diversity of cognitive

domains and were chosen on the basis of four primary considerations: (a)
assessing cognitive processes that are relevant to the everyday function of
older people; (b) using tasks that are known to be sensitive to age-related
decline; (c) avoiding floor effects (too many people failing) and ceiling effects
(too many obtaining maximum scores); and (d) employing measures used in
other studies to facilitate comparisons. The cognitive processes that were
assessed include learning and memory, word-finding ability, executive
function, speed of processing and numerical ability. Given the primacy of
memory in age-related cognitive impairment, memory assessment is further
subdivided into retrospective memory (recalling information that was learned
previously) and prospective memory (remembering to carry out an intended
action). The term ‘executive function’ refers to a number of cognitive control
processes, which include attention, initiation, set-shifting or mental flexibility,
organisation, abstraction, planning and problem-solving. The non-memory
tasks used in ELSA tap into a number of these processes (see below).
The specific cognitive measures used in ELSA wave 1 are as follows:

Memory measures
1. Self-rated memory – this measure provides an indication of whether the
respondent is worried about their memory. They are asked to rate whether
their memory at the present time is excellent, very good, good, fair or poor.
The item comes from the HRS.
2. Orientation in time – knowing the day and date is a simple but effective
test of memory. Time orientation was assessed by standard questions about
the date (day, month, year) and the day of the week. This item is included
in the HRS and forms part of the Mini-Mental State Examination (MMSE)
which is used in numerous studies of ageing.
3. Word-list learning – this is a test of verbal learning and recall, in which 10
common words are presented aurally and the participant is asked to
remember them. Word recall is tested both immediately and after a short
delay that is filled with other cognitive tests. ELSA uses the word lists
developed for HRS, which comprise four different versions, so that
different lists can be given to different members of the same household.
The first member of the household to be tested is assigned a list at random
by the computer, and where there is more than one member of the
household in the ELSA sample, the remaining lists are also selected at
random. To ensure standardisation, the lists are presented by the computer,
using a taped voice.
4. Prospective memory – sometimes referred to as ‘remembering to
remember’, prospective memory concerns memory for future actions.
Early in the cognitive assessment section, respondents are informed about
two actions that they will be asked to carry out at the appropriate time,
later in the session. They are told that they will need to carry out these
actions without being reminded. The first task is to remember to write their
initials in the top left-hand corner of a page that is attached to a clipboard,
when they are later handed the clipboard. The second task is to remember

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to remind the interviewer to record the time when the interviewer

announces that the cognitive section is finished. When the appropriate
point is reached for the respondent to carry out the actions, the interviewer
waits for five seconds to see if the respondent performs the correct action
without a prompt. If they fail to carry out the action spontaneously, the
interviewer reminds them that they were going to do something and
records what the respondent then did. A correct response requires the
person to carry out the correct action without being reminded. The first
task is based on a similar task used in the Medical Research Council
Cognitive Function and Ageing Study (MRC CFA Study, 1998), and the
second task is based on a similar task used in the Rivermead Behavioural
Memory Test (Wilson, Cockburn and Baddeley, 1985).

Executive function / other cognitive items

1. Word-finding (verbal fluency) – this is a test of how quickly participants
can think of words from a particular category, in this case naming as many
different animals as possible in one minute. Successful performance on
this test requires self-initiated activity, organisation and abstraction
(categorising animals into groups such as domestic, wild, birds, dogs) and
set-shifting (moving to a new category when no more animals come to
mind from a previous category).
2. Letter cancellation – this is a test of attention, visual search and mental
speed. The participant is handed a clipboard to which is attached a page of
random letters of the alphabet set out in rows and columns, and is asked to
cross out as many target letters (P and W) as possible within one minute.
An example is given at the top of the page to show the respondent how to
cross out the letters. The page comprises 26 rows and 30 columns, and
there are 65 target letters in all. Respondents are asked to work across and
down the page as though they were reading and to perform the task both as
quickly and as accurately as possible. When the time is up, the respondent
is asked to underline the letter they reached. The total number of letters
searched provides a measure of speed of processing. The number of target
letters (P and W) missed up to the letter reached by the respondent
provides a measure of accuracy. This test was developed for the 1946 birth
cohort study (Richards et al., 2001) and has also been used in the MRC
Cognitive Function and Ageing Study (MRC CFA Study, 1998).
3. Numerical ability – this aims to establish the participant’s level of
numeracy by asking them to solve problems requiring simple mental
calculations based on real-life situations. The test begins with three
moderately easy items to provide a rapid assessment of ability level.
Respondents who make errors on all these items are then asked an easier
question. Respondents who get any of the first three questions correct are
then asked two progressively more difficult questions (and given credit for
the easiest question). A score of 1 is given for correct answers on the first
five questions, and for the final question (calculation of compound
interest), a score of 1 is given if the answer is almost correct and a score of
2 if the answer is fully correct. These items were developed for ELSA and
have also been used in HRS in an experimental module.

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Summary cognitive measures

For some purposes, it is useful to derive summary cognitive performance
measures. Accordingly, we have derived a memory index, an executive
function index and a global cognitive index which combines the two in the
derivation of these summary measures. Some test scores have been recoded.
The memory index combines all the scores on the objective memory tests and
has a range of possible scores from 0 to 30. The executive function index
combines all the scores on the other cognitive tests and also has a range of
possible scores from 0 to 30. The global cognitive index combines these two
to produce a score ranging from 0 to 60.

7.3 Findings on physical function

Activities of daily living (ADLs)
The prevalence of reported difficulty with ADLs increases with age, with
10.6% of respondents aged 50–54 reporting difficulty, compared with 41.9%
of those aged 80 and over. This comparatively high rate of disability in
younger respondents, while many older respondents report no difficulty with
ADLs, demonstrates that disability and age are not synonymous, and is
consistent with previous studies (Manton, 1989). (Table 7A.1, Figure 7.1)

Figure 7.1. Difficulty with activities of daily living (ADLs), by age

50

40

30
%

20

10

0
50-54 55-59 60-64 65-69 70-74 75-79 80 & over
age group

difficulty with 1 or more ADL (%)

There is very little difference between the sexes for reported difficulty with
ADLs, although disability is slightly higher in men than in women up to age
64, and in women than in men over age 64 (44.1% for women and 38.1% for
men over 80 years old) (Table 7A.1). Particularly high rates of difficulty were
reported for dressing and bathing (13.4% and 12.5% respectively) (Table
7A.2).
There is considerable difference between occupational classes for reported
difficulty with ADLs. Overall, the rates of difficulty with ADLs are 14.0% for

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those with managerial and professional occupations and 25.5% for those with
routine and manual occupations. The excess disability in routine and manual
occupational classes, compared with managerial and professional occupational
classes, is present in all age groups. The rates of difficulty with ADLs reported
by respondents in routine and manual occupational classes are 17.8% for ages
50–59 and 38.4% for ages 75 and over. For those in managerial and
professional occupational classes, the rates are 7.7% for ages 50–59 and
29.2% for ages 75 and over. The relative difference between occupational
classes thus decreases with age, whilst the absolute difference remains similar
(17.8 is more than twice as high as 7.7, but 38.4 is less than a third as high
again as 29.2, whilst the absolute differences are 10.1 and 9.2). (Table 7A.3,
Figure 7.2)

Figure 7.2. Difficulty with one or more activity of daily living (ADL), by age and
occupational class

45
40
35
30
25
%

20
15
10
5
0
50-59 60-74 75 & over
age group

managerial / professional intermediate routine / manual

Instrumental activities of daily living (IADLs)

Again, the prevalence of reported difficulty with IADLs increases with age,
with 12.2% of respondents aged 50–54 reporting difficulty, compared with
48.8% of those aged 80 and over. These percentages are only very slightly
higher than the percentages for ADLs. There is a big increase (from 28.6% to
48.8%) in the number reporting difficulty with IADLs between the 75–79 age
band and the 80-and-over band. Overall, women report more difficulty with
IADLs than men do at all ages (25.1% and 17.5% respectively). (Table 7A.4)
Particularly high rates of difficulty were reported for doing work around the
house and garden (16.2%) and shopping for groceries (9.7%). The over-75s
reported problems more than twice as often as those aged 60–74 in both sexes
for nearly all IADLs, suggesting that there is a threshold around age 75. (Table
7A.5)
The difference between the occupational classes for IADLs follows a similar
pattern to that described above for ADLs. Overall, the rates of difficulty with
IADLs were 14.1% for those with managerial and professional occupations

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and 26.2% for those with routine and manual occupations. The excess
disability in routine and manual occupational classes, compared with
managerial and professional occupational classes, is present in all age groups.
The rates of difficulty with IADLs reported by respondents in routine and
manual occupational classes are 18.3% for ages 50–59 and 42.4% for ages 75
and over. For those in managerial and professional occupational classes, the
rates are 8.4% for ages 50–59 and 33.1% for ages 75 and over. The relative
difference between occupational classes thus decreases with age, whilst the
absolute difference remains similar (18.3 is more than twice as high as 8.4, but
42.4 is less than a third as high again as 33.1, whilst the absolute differences
are 9.9 and 9.3). For IADLs, the difference between occupational classes is as
big as the difference between age groups. 18.3% of the youngest respondents
(aged 50–59) with a routine or manual occupation report a difficulty with an
IADL, compared with only 11.8% of older respondents aged 60–74 with a
managerial or professional occupation. (Table 7A.6)

Mobility (leg) and arm function

As expected, the prevalence of reported difficulty with mobility and arm
function increases with age, with 39.7% of respondents aged 50–54 reporting
difficulty, compared with 82.7% of those aged 80 and over. Higher rates of
difficulty were reported with mobility than with IADLs or ADLs. Women
report more difficulty with mobility and arm function than men do at all ages
(64.0% and 49.2% respectively). (Table 7A.7, Figure 7.3)

Figure 7.3. Difficulty with mobility items, by age

100
90
80
70
60
%

50
40
30
20
10
0
50-54 55-59 60-64 65-69 70-74 75-79 80 &
over
age group

difficulty with 1 or more mobility item (%)

High rates of difficulty were reported by both sexes with climbing several
flights of stairs (men up to 48.4%, women up to 59.7%), stooping, kneeling or
crouching (men up to 47.3%, women up to 58.2%), lifting or carrying heavy
weights (men up to 28.6%, women up to 55.3%) and getting up from a chair
after sitting for long periods (men up to 33.3%, women up to 41.6%). There is
a big increase in the proportion of both sexes reporting problems with all

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items, except sitting, between the 60–74 age group and the over-75 age group.
(Table 7A.8)
The difference between the occupational classes for mobility is similar but
slightly smaller than that described above for IADLs and ADLs. Overall, the
rates of difficulty with mobility are 47.1% for those with managerial and
professional occupations and 63.2% for those with routine and manual
occupations. The excess disability in routine and manual occupational classes,
compared with managerial and professional occupational classes, is present in
all age groups. The rate of difficulty with mobility and arm function reported
by respondents in routine and manual occupational classes is 50.3% for ages
50–59, and 80.6% for ages 75 and over. For those in managerial and
professional occupational classes, the rates are 35.1% for ages 50–59 and
72.5% for ages 75 and over. Both the relative and absolute differences
between occupational classes thus decrease with age (50.3 is 43% more than
35.1, but 80.6 is only 11% more than 72.5, whilst the absolute differences are
15.2 and 8.1). Some of this decreased gap between occupational classes may
be due to a ceiling effect, due to the high rates of older respondents reporting
difficulty with the mobility measures. (Table 7A.9)

Walking speed
Walking speed was measured only in those aged 60 and over, and only those
who successfully completed both walks were entered into the analysis here.
The proportion of respondents walking at 0.4 metres/second (m/s) or slower
increases with age, from 2.7% at age 60–64 to 19.4% at age 80 or over. The
median speed in m/s decreases with age, from 0.94 at age 60–64 to 0.61 at age
80 or over. The proportion of women walking slower than 0.4 m/s is higher
than the proportion of men after age 65, and the gap widens with increasing
age, to 22.8% of women and 13.7% of men at age 80 and over. (Table 7A.10)

Falls
Questions on falls were asked only of those aged 60 and over. Of those asked,
32.0% had fallen down in the last two years. The prevalence increased with
age, from 25.6% of those aged 60–64 to 47.3% of those aged 80 and over.
More women than men had fallen in the last two years (37.2% and 25.7%
respectively). Of those who had fallen, 38.2% had needed medical treatment
as a result of the fall. (Table 7A.11)
In men (but not women), the percentage of falls resulting in medical treatment
stayed fairly constant, at around 30%, even though the percentage of men who
fell increased with age from 20.8% to 43.1%. In women, the percentage of
falls resulting in medical treatment increased as the percentage of women who
fell increased, from around 30% to around 50%.

Problems with eyesight, hearing and incontinence of urine

The percentage reporting fair or poor eyesight increases with age after about
age 70, from 12.6% for ages 65–69 to 32.7% at age 80 and over. The
percentage reporting fair or poor hearing increases with age after about age 60,

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from 15.6% at ages 55–59 to 39.2% at age 80 and over. For eyesight, there is
little difference between the sexes, but for hearing, 1.5 to 2 times as many men
as women report difficulties at all ages except 80 and over. (Table 7A.12)
The percentage reporting being incontinent also increases with age, and was
much higher for females than for males in all age groups. The size of the
difference between men and women reporting being incontinent narrows with
increasing age. In the 50–54 age group, 3.1% of men and 17.9% of women
report being incontinent, whereas in the over-80 age group, the figures are
18.8% for men and 25.5% for women. (Table 7A.13)

Receipt of help for those reporting difficulty

Out of all those reporting difficulty with one or more ADL, IADL or mobility
and arm function, 40.6% received help. The percentage receiving help
increased with age, from 33.0% at age 50–59 to 53.9% at age 75 and over. At
all ages, women received more help than men (for example, 39.6% and 32.2%
respectively receiving help at age 60–74).
The commonest sources of help overall (percentage of all who reported
difficulty with an ADL, IADL or mobility function) were spouse or partner
(21.4%), daughter (11.2%), son (7.5%), other unpaid individual (7.3%) and
paid individual (6.7%). Unpaid individuals included other relatives, voluntary
workers, and friends and neighbours. Very low percentages received help from
parents, and this decreased further with increasing age, to 0.1% at age 75 and
over, as expected. Little help was received from siblings (1.6%) or
grandchildren (2.3%), although grandchildren provided some support for their
grandparents aged over 75 years (4.6%).
Nearly all sources of help increased with increasing age, except for help from
a spouse, which remained roughly constant for men (21.0% at age 50–59 and
23.7% at age 75 or over) and decreased markedly for women aged 75 and over
(from 26.0% at age 50–59 to 12.0% at age 75 or over). Paid help for women
aged 75 and over increased markedly to 19.8%, from 3.8% at age 60–74. In
men, paid help increased from 2.7% at age 60–74 to 10.5% at age 75 or over.
(Table 7A.14)

Use of aids for those reporting difficulty

Out of all those reporting difficulty with one or more ADL, IADL or mobility
and arm function, 30.4% used an aid. The percentage using an aid increased
with age, from 15.4% at age 50–59 to 52.7% at age 75 or over. By far the most
common aid used (percentage of all who reported difficulty with an ADL,
IADL or mobility function) was a cane or walking stick (26.8%). 4.8% used a
personal alarm, 4.2% a manual wheelchair and 3.5% a Zimmer frame or
walker. The use of personal alarms and Zimmer frames increased markedly in
the 75-and-over age group. Personal alarms were used by 2.4% of respondents
aged 60–74 and 12.0% aged 75 and over. Zimmer frames were used by 1.7%
of respondents aged 60–74 and 8.9% aged 75 and over. (Table 7A.15)

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7.4 Findings on cognitive function

Memory
Self-reported problems with memory were present in almost a third of the total
sample, with 32.3% rating their memory as fair or poor rather than excellent,
very good or good (Table 7A.16). In men, the measure showed a steady
increase with age, with 28.7% describing their memory as fair or poor in the
youngest group rising to 40.4% in the oldest group. However, a very different
pattern emerged for women. Those aged 65–69 reported the lowest percentage
of problems. Indeed, the percentage reporting fair or poor memory fell steadily
between ages 50–54 and ages 65–69, then began to rise. There was also an
interesting pattern of gender differences. At ages 60 and over, women were
less likely than men to report fair or poor memory, while at ages under 60,
women were more likely than men to report fair or poor memory. Self-
reported memory was also related to level of education (Table 7A.17). The
higher the level of education, the smaller the percentage who reported their
memory to be fair or poor. This pattern was seen for men and women in each
age group. The association between self-rated memory and occupational class
was similar to the association between self-rated memory and education – the
higher the occupational class, the smaller the percentage reporting their
memory as fair or poor (Table 7A.18). It is interesting that this finding
conflicts with the earlier results of Rabbitt and Abson (1990), who used a
volunteer sample. Volunteers often included the ‘worried well’, which may
account for the discrepancy.
In the ELSA sample as a whole, 23.1% made at least one error on time
orientation (day, month, year, day of week). The percentage making an error
increased progressively with advancing age, from 15.0% in the youngest
group to 36.8% in the oldest (Table 7A.19), and this trend was seen for both
men and women. Of those who made an error, the great majority made only
one error, which was usually giving an incorrect day of the month. Women
performed better than men in every age group, and this gender difference was
particularly evident for the percentage making two or more errors in the
younger age groups. There was an overall effect of educational level and
occupational class on this test, in the expected direction (Williams et al.,
2003), with most errors in the groups without educational qualifications or in
routine and manual occupations (Tables 7A.20 and 7A.21).
For the sample as a whole, the mean number of words recalled from the 10-
word list was 5.4 immediately and 3.9 after a delay. As expected, the older the
group, the fewer the words they recalled. The youngest group recalled an
average of 6.2 words immediately and 4.9 after a delay, compared with the
oldest group, who recalled 3.9 words immediately and 2.1 after a delay (Table
7A.22). Figure 7.4 shows the mean number of words retained after the delay
as a percentage of the mean number recalled immediately. This shows that
even after a short delay, older people recall a much smaller proportion of the
information they acquired. Women outperformed men on the word-recall task
in every age group, on both immediate and delayed recall. The advantage
shown by women on this verbal learning task is in line with numerous other
studies (Huppert and Whittington, 1993; Portin et al., 1995; Maitland et al.,

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Physical and cognitive function

2000). Higher educational level was strongly associated with better

performance on this task, as expected, and the effect was seen in every age
group for both men and women and for both immediate and delayed recall
(Table 7A.23). A similar pattern of results was seen for occupational class but
the effect was smaller than that for education (Table 7A.24).

Figure 7.4. Mean delayed word recall as percentage of mean immediate recall

90
80
70
60
percentage

50 males
40 females
30
20
10
0
50-59 60-74 75+
age group

On the two tests of prospective memory, almost half of the sample forgot to
carry out the specified actions without being reminded (48.8% and 49.6% for
the initials and time-recording tasks respectively – Table 7A.25). As expected,
performance decreased steadily with increasing age. Just over a third of
respondents in the youngest age group failed to carry out the appropriate
actions without a reminder, compared with over two-thirds of those in the
oldest age group (69.8% on the initials task and 78.3% on the time-recording
task in the oldest group). On both prospective memory tasks, men
outperformed women in every age group. The direction of the gender
difference on these two tasks in ELSA contrasts with the findings from the
MRC Cognitive Function and Ageing Study, in which a similar test was
administered in a population sample of almost 12,000 respondents aged 65 and
over (Huppert et al., 2001). On this task, women were 11% more likely than
men to perform correctly without a prompt. Further investigation is required to
establish why women performed better than men on the MRC CFAS
prospective memory task but not on the two tasks used in ELSA.
There was a strong effect of educational level on these tasks: well over half of
the group without educational qualifications failed to carry out the required
actions without a reminder (Table 7A.26). The effect of education was evident
in every age group and particularly pronounced in the oldest group, where
amongst those with no educational qualifications, around 70% failed on the
initials task and over 75% failed on the time-recording task. The gender
difference on these tasks reported above appears to be partly explained by
gender differences in education, since when education was matched (Table
7A.26), women performed better than men in about a third (3/9 and 4/9) of the
age-by-education comparisons for each task. As was the case for the word-

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 Physical and cognitive function

recall test, the effect of occupational class was very similar to the effect of
education but somewhat smaller (Table 7A.27).
To the extent that these tasks provide an indication of prospective memory in
everyday life, the high prevalence of age-associated forgetfulness is a cause
for concern, particularly in the oldest age groups. These findings raise
questions about the extent to which older individuals remember to carry out
essential actions such as those concerned with health (taking medication),
security (locking doors, turning off the cooker) and economic activity
(collecting pensions, checking statements). There may be less of a problem
remembering appointments, social commitments or family events, since there
is evidence from experimental research that older people are more likely than
younger people to record appointments and important dates in diaries or
calendars, whereas young adults tend to rely on their memory (Moscovitch,
1982).

Executive / other cognitive performance

The number of different animal names that ELSA respondents produced on the
verbal-fluency task ranged from 0 to 52, with an overall mean of 19.1. 10% of
the sample produced 10 animal names or fewer, and 6% of the sample
produced 30 or more. As expected, there was a progressive decrease in the
number of animal names produced with advancing age (Table 7A.28). On
average, respondents aged 50–54 produced 21.9 different animal names,
compared with 14.6 in respondents aged 80 and over. There was also a gender
difference, with men showing an advantage over women, particularly in the
older age groups. However, this gender difference partly reflects gender
differences in education, since in the group with a degree or higher education,
women performed slightly better than men overall, and this trend was only
reversed at age 75 and over (Table 7A.29). Occupational class also exerted an
effect on verbal fluency, which was the same for men and women, and smaller
than the effect of education (Table 7A.30).
The letter-cancellation task provided measures of both speed and accuracy of
performance. The speed measure was the number of letters that were searched
during the one-minute interval, and ranged from 16 to 780, with a mean of
305. The mean number of letters searched decreased, as expected, with
advancing age, from 328 in the youngest group down to 257 in the oldest
(Table 7A.31). Women performed better than men on this measure and the
gender difference was seen in every age group. The effect of education on
speed of processing was in the expected direction and was evident for both
sexes and each age group (Table 7A.32). The effect of occupational class was
in the expected direction for men, but for women, there was no discernible
difference between those in intermediate occupations and those in routine and
manual occupations (Table 7A.33). Accuracy of performance was measured in
terms of the number of target letters missed, i.e. the number of letters P and W
that were not crossed out up to the point the respondent reached. This value
ranged from 0 to 52 out of a maximum of 65 targets. The average number
missed was 5.5, this number increasing with age up to age 70–74 and
remaining stable thereafter (Table 7A.31). Women missed more targets than
men – an average of 5.7 versus 5.3 for men. There was an interesting effect of

265
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education and occupational class on the accuracy measure (Tables 7A.32 and
7A.33). For both men and women, respondents with an intermediate level of
education showed the highest level of accuracy overall (i.e. the lowest number
of targets missed). Likewise, women in intermediate occupations showed the
highest level of accuracy overall, although this was not the case for men.
It is useful to consider the results of the letter-cancellation task in terms of the
well-known trade-off between speed and accuracy. In general, an individual
can maximise either their speed of performance or their accuracy of
performance but not both. A similar pattern can often be seen in group data.
The gender differences reported above are consistent with the notion of a
speed–accuracy trade-off, since women were both faster and less accurate than
men. A similar pattern was observed for education, where respondents with a
degree or higher education were faster and less accurate than those with an
intermediate level of education (Table 7A.32). Likewise, women in
professional or managerial occupations were faster and less accurate than
women in intermediate occupations, although this effect was not observed for
men (Table 7A.33). There was also some degree of speed–accuracy trade-off
with respect to age: while search speed decreased progressively with age,
respondents in the oldest age groups (70–74, 75–79, 80+) maintained their
level of accuracy (Table 7A.31). On the other hand, respondents in the
youngest age group were both faster and more accurate than older
respondents, while respondents who had no educational qualifications or were
employed in routine or manual jobs were both slower and less accurate than
other groups (Tables 7A.32 and 7A.33).
The average score on the tests of numerical ability was 4.4 out of a possible
total of 7.3% of the sample got none of the answers correct, and 11.4% got all
the answers correct. Performance on these tests showed substantial age and
gender differences (Table 7A.34). The youngest group obtained an average
score of 5.0, compared with the oldest group, whose average was 3.5. The
average score for women was 4.0 compared with 4.8 for men, and the gender
difference was apparent in every age group. Performance was related to level
of education and occupational class and the effects of these two variables were
the same for both genders and all ages (Tables 7A.35 and 7A.36). It is
noteworthy that on the numeracy task, the oldest group with a degree or higher
education performed better than the youngest group with no educational
qualifications. This can be seen for women in Figure 7.5. The relatively low
numeracy of certain groups – notably the poorly educated, women and the
elderly – provides cause for concern if we assume that the measures of
numeracy used in ELSA are indicative of numerical ability in daily life. In our
computerised age, there is unprecedented access to numerical information and
we are increasingly deluged with data. Indeed, a seminal publication entitled
Mathematics and Democracy argues that individuals who lack the ability to
think numerically cannot participate fully in civic life (Steen, 2001). Certainly,
individuals whose numerical ability is limited will be hampered when faced
with many important decisions about finances, lifestyle and health. Making
sensible decisions about savings and pensions, and understanding the risks
involved in health-related behaviours or medical treatments, depend in part on
numerical ability and quantitative reasoning. Future waves of ELSA will

266
 Physical and cognitive function

examine the comparative effects of ageing and cohort differences on numeracy

and its impact on behaviour.

Figure 7.5. Numerical ability, by age and education: women

5
mean numeracy score

degree/higher
3 intermediate
no quals

0
50-59 60-74 75+
age group

Summary cognitive measures

A memory index has been derived from all the objective memory tests used in
ELSA, and scores on the memory index spanned the full range of possible
values from 0 to 30. An executive function index has also been derived from
all the non-memory items, and scores on the executive index ranged from 4 to
29. Finally, we derived a global cognitive index combining scores on all the
objective cognitive tests, and scores on the global cognitive index ranged from
5 to 55 (out of a maximum of 60). For the ELSA sample as a whole, all three
of these measures form a near-normal distribution, with no evidence of floor
or ceiling effects. This distribution of scores makes these summary measures
very suitable for detecting change in the longitudinal component of ELSA.
Mean scores on the global cognitive index are shown in Table 7A.37, by age,
gender and education. Figure 7.6 shows the distribution of the global cognitive
index by age group. It can be seen that the distribution of scores becomes
broader with advancing age, indicating increasing heterogeneity among the
older groups. The graph also shows the large area of overlap in cognitive
capability between different age groups.
Cognitive capability is likely to be related to measures of physical function,
particularly the ability to perform instrumental activities of daily living
(IADLs), which make demands on both physical and cognitive function. This
association is seen in Table 7A.38. Within each age group, the mean score on
the global cognitive index decreases as the number of IADL problems

267
Physical and cognitive function

Figure 7.6. Distribution of global cognitive index, by broad age band

.06
.04
Density
.02
0

0 10 20 30 40 50 60
Cognitive index
Age 50-59 Age 60-74
Age 75 or over

increases. The mean cognitive index score was 34.7 for those reporting no
difficulties with IADLs, 30.1 for those reporting 1–2 difficulties and 26.1 for
those reporting 3 or more difficulties with IADLs. The association between
physical and cognitive function may be due to a common underlying cause,
such as age-related physiological changes, or to other factors associated with
both physical and cognitive impairment, such as occupational class.

7.5 Conclusions
Disability or impairment of function is a key marker of population health and
independence at all ages. This chapter has described the variation in physical
and cognitive function between age groups, and the effects of occupational
class and education, for people aged 50 and over in England. The levels of
physical and cognitive impairment are surprisingly high in the younger age
groups, especially in those with no educational qualifications and in routine
and manual occupations. In contrast, many older respondents reported and
showed no difficulties with physical and cognitive function. In general,
physical and cognitive function is associated with education and occupational
class, with respondents from managerial and professional occupations and/or
with higher levels of education performing better and reporting fewer
difficulties with function.
The results presented are all from the cross-sectional data in wave 1 of ELSA
and provide important information about disability and impairment of
function. The differences in function at different ages shown by the cross-

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 Physical and cognitive function

sectional data presented in this chapter are due to differences between cohorts
as well as to the effects of ageing. Data from future waves of the study will
provide information on trajectories of health, disability and impairment of
function. Until the longitudinal data become available, it is not possible to
separate the relative contribution of age and cohort effects. The most useful
information for policy-makers will come from the comparison of this cross-
sectional data with data from the same respondents to be collected in wave 2
and future waves of ELSA. The longitudinal design of ELSA allows for
repeated collection over time of the data presented here, as well as future
collection of detailed data on objective physical performance measures and on
the quality of health care received. This will inform policy debates about the
manner in which health, health care and social and economic circumstances
interact over time, and the extent to which they each affect disability and
functional decline.

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